Provider Demographics
NPI:1407116916
Name:KETTINGER, STUART ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:ALLEN
Last Name:KETTINGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 TATE SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-1109
Mailing Address - Country:US
Mailing Address - Phone:434-200-3000
Mailing Address - Fax:
Practice Address - Street 1:1901 TATE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:434-200-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100681207P00000X, 390200000X
VA0101257784207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program